September 19, 2017

Cassidy-Graham bill resurrects GOP efforts to repeal ACA. But could it pass?

Daily Briefing

Correction: An earlier version of this story incorrectly stated the Cassidy-Graham bill's effect on the traditional Medicaid program.

A Senate GOP bill (HR 1628) to repeal parts of the Affordable Care Act (ACA) appears to be gaining traction among lawmakers, but so far the bill does not have the 50 votes needed to secure passage.

The bill—introduced last week by Republican Sens. Lindsey Graham (S.C.), Bill Cassidy (La.), Dean Heller (Nev.), and Ron Johnson (Wis.)—has been portrayed as the last option for GOP lawmakers to fulfill their promise to repeal the ACA. GOP Senators face a Sept. 30 deadline to pass the bill on a simple majority vote under the budget reconciliation process.

In a state of reform: Profiles of innovative state-level Medicaid transformation

The measure would repeal the ACA's individual and employer mandates retroactively to 2016, as well as the law's taxes on non-qualified spending from health savings accounts (HSAs), medical devices, and over-the-counter medications. Like the Senate's Better Care Reconciliation Act, the Cassidy-Graham bill would reform the Medicaid program by shifting its funding structure to a per capita cap system. The bill also would put in place a new state block grant system for providing coverage to low-income individuals.

Momentum builds

After a Monday morning meeting with Senate Majority Leader Mitch McConnell (R-Ky.), Sen. John Thune (R-S.D.) said, "The odds are improving," adding, "I told Bill Cassidy he's the grave robber. This thing was 6 feet under. And I think he's revived it to the point that there's a lot of positive buzz and forward momentum."

So far, only one GOP senator—Sen. Rand Paul (R-Ky.)—has said that he will vote against the bill. Paul said the bill does not go far enough to repeal the ACA.

However, many GOP senators—including Sens. Susan Collins (Maine), John McCain (Ariz.), and Lisa Murkowski (Alaska), who all voted against the Senate GOP's final repeal bill in July—have said they are still reviewing the bill.

McCain noted that Arizona Gov. Doug Ducey's (R) decision Monday to come out in favor of the bill "obviously has some impact," but added that "the fact is we have also not gone through the regular order."

Collins said, "Based on my analysis, I'm concerned about what the effect would be on coverage, on Medicaid spending in my state, on the fundamental changes in Medicaid that would be made." Murkowski similarly said she has to determine how her state would be affected before making a final decision. However, her state's governor, Gov. Bill Walker (R), on Tuesday raised concerns about the proposal, saying, "Given Alaska's current fiscal challenges, any proposal to shift federal costs to the states would likely result in drastic cuts to our Medicaid program."

The senators will have to make those determinations without a full score from the Congressional Budget Office (CBO). In response to a request from Senate Majority Leader Mitch McConnell (R-Ky.) to score the bill, CBO on Monday said it will provide lawmakers with some basic budgetary estimates by next week, but it will not be able to project how the bill would affect the uninsured rate or premiums before the Sept. 30 deadline.

Meanwhile, Senate Finance Committee Chair Orrin Hatch (R-Utah) has scheduled a hearing Monday to discuss the bill. Hatch said, "Senators have expressed a strong desire to examine the details of the Graham-Cassidy proposal through a public hearing," adding, "A hearing will allow members on both sides of the aisle to delve deeper into its policy and gain a better understanding of what the authors hope to achieve."

Johnson, who chairs the Senate Homeland Security and Governmental Affairs Committee, also announced that his panel will hold a hearing on Sept. 26 to discuss health care block grants, which according to Politico's "Pulse" is "a clear reference" to the Graham-Cassidy bill.

The bill's prospects

The Senate is out of session on Thursday and Friday, meaning it has just five legislative days next week to secure the 50 votes needed to pass the bill, presuming that the vice president serves as a tie breaker.

But even though time is short, Timothy Jost, professor of law emeritus at Washington and Lee University, said Republicans still have enough time to pass the bill if they can find the needed support. Jost said, "At this point, my understanding is that all the time allotted for debate under reconciliation rules has been used, and all it would take is for McConnell (R-Ky.) to bring the bill to the floor and move for a substitute amendment, and then go into 'votearama'—and if it had the votes, they would be able to get it passed and send it on to the House and onto the president's desk."

House Freedom Caucus Chair Mark Meadows on Monday suggested that the House would pass the Cassidy-Graham bill if it clears the Senate, Politico reports. However, Meadows said that if the bill is changed significantly to appeal to moderate Senate Republicans, that could jeopardize the votes of conservative lawmakers in the House.

House Speaker Paul Ryan (R-Wis.) on Monday also said the House would likely take up the bill, calling it the GOP's "best, last chance" to repeal and replace the ACA.

Democratic leaders hold talk-a-thon, request full CBO analysis of health reform bill

Senate Democrats on Monday night held an almost four-hour talk-a-thon—from about 7 p.m. to 11 p.m.—to protest the latest bill aimed at repealing and replacing the ACA, according to The Hill.

During the talk-a-thon, Democrats lambasted the proposed bill and called on moderate and swing-vote Republicans who have wavered on previous iterations of repeal-and-replace legislation to refuse to support the Graham-Cassidy proposal. Democrats also are mobilizing several industry groups and liberal advocacy groups to protest the bill.

Senate Democrats earlier that day also criticized their Republican colleagues for considering a vote without a full CBO score. Senate Minority Leader Chuck Schumer (N.Y.) said Democrats would use every procedural tool to delay or stop the passage of the Cassidy-Graham bill. For instance, according to Politico, Democrats are likely going to use next week's hearings on the proposal's block grants to critique the measure. However, Democratic senators and aides on Monday said serious conversations about what Democrats would do if the bill comes to the floor would likely come later. Possible steps could include introducing amendments to push debate on the bill past Sept. 30, Politico reports.

Industry groups come out against bill

The health care industry also has voiced concerns about the Graham-Cassidy bill, organizing rallies, ad campaigns, town-hall-style events, and phone bank efforts to protest the measure, Modern Healthcare reports.

According to Modern Healthcare, provider, industry, and consumer groups have expressed concerns that the bill would spur major coverage losses and erode consumer protections. Hospital groups that have come out against the bill include America's Essential Hospitals, the California Hospital Association, the Colorado Hospital Association, and the Kansas Hospital Association (KHA).

Meanwhile, the Association for Community Affiliated Plans (ACAP) is gearing up to relaunch a social media campaign in Arizona against the proposal, and other groups—including Planned Parenthood, MoveOn, the Center for American Progress, and Arc—are planning to hold a rally Tuesday against the bill.

Claire McAndrew, director of campaign strategy for Families USA, said, "We are working with our state partners across the country to make sure members of Congress don't vote for a proposal to slash funding for consumer protections and funding for Medicaid and marketplace subsidies." 

Margaret Murray, CEO of ACAP, said news of the latest bill comes as a disappointment, because the association "thought Congress was finally making progress toward bipartisan solutions on stabilizing the market and reauthorizing CHIP."

Separately, Cindy Samuelson, VP for public relations at the KHA, said, "We will continue to urge our senators to address the challenges facing our health care system, protect health coverage, and oppose the (Graham-Cassidy) bill" (Frieden, MedPage Today, 9/18; Stolberg, New York Times, 9/19; Everett/Haberkorn, Politico, 9/19; Sullivan, The Hill, 9/18; Viebeck, "PowerPost," Washington Post, 9/18; Bade, Politico, 9/18; DeBonis, "PowerPost," Washington Post, 9/18; Wong, The Hill, 9/18; Granger, Daily News-Miner, 9/19). (Schor, Politico, 9/18; Cornwell, Reuters, 9/18; Carney [1], The Hill, 9/18; Carney [2], The Hill,  9/18; Meyer, AP/Modern Healthcare, 9/18).  

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